Monday, April 19, 2010


I walked into the procedure room, and introduced myself to a dark-skinned man whose youthful countenance and casual running gear belied the mid-seventies age written on the requisition form by at least 15 years.

"Did the tech tell you about the procedure?"


"Do you have any questions?"


I grabbed the syringe off of the counter and opened the plastic package on the sterile needle. Applied the needle to the syringe, and got frustrated.

"I hate the slip-tip. Can you get me the other syringe? (They know this)."

The tech apologized and started rooting around in the drawer. I don't recall the fancy name for the syringes I like, but I recalled aloud the reason for my preference.

"Once, during my training, I was squirting the specimen into the formalin bottle, and the needle fell off of the slip-tip syringe. Not only did specimen splash up into my eye, the formalin bottle tipped over and the specimen was lost. I really hate these syringes."

All of a sudden, I remembered there was a patient in the room, and rushed to console him. "That has only happened once, and I've hundreds of needles under my belt, since then. Don't worry."

The tech finally found the screw-top syringe, and I fastened the needle. Palpated the mass on the right side of the patient's face - a small centimeter lesion that was slow-growing, according to the clinical history, and cystic, according to the radiology.

Before I made a first pass at the lesion, I loosened the patient up with small talk.

"What did, or do, you do for a living?"

"Teach. Got a 45 year career in my former life. English. I also coached basketball."

"What ages?"

"Ninth to eleventh grades."

I looked at him in awe, as I applied the alcohol pad to his face to sterilize the skin. "I am honored to perform a needle on you. Those are rough ages to teach. Lots of hormones swimming around for distraction."

He laughed, and I worked the small mass in front of his ear with two fingers to isolate it. Steadied my gun, and gave a warning call. "Bee sting now."

I could tell it hurt by the expression on his face. I was a little relieved, since malignant lesions are usually painless. I liked this guy, and didn't want to give him a cancer diagnosis. Negative pressure yielded a few drops of serosanguinous fluid in the hub of the syringe - confirmation that I was in the dead center of the cyst.

After the tech stained the slides, I looked through the scope. Often when we get cyst fluid, it is impossible to make a diagnosis, because there are only inflammatory cells - nothing to lead toward a defining etiology for the lesion.

"I am going to make one more pass, and then call it quits. We'll have all of the material available for diagnosis tomorrow, and I'll call your clinician (I trained with him - he is an excellent ENT, and I told this to the patient) to give him a preliminary diagnosis."

I prepared the second needle, and applied more alcohol. Decided to tell a story while I was doing the fine needle aspirate - he was obviously uncomfortable the first time and sometimes stories can be a welcome distraction.

"I was recruited hard by my high school basketball coach, because of my height. I was pretty shy in high school, so I resisted him for a long time. I realize in retrospect he probably looked at me and had big dreams of making a star."

Needle in. I was guiding it back and forth in the lesion in quick stabbing motions, trying to catch cystic lining cells that might hint at the nature of the mass.

"I finally caved, and joined the team for off-season training as a junior. I was great at the weights, and when I was the only person on the court I could get the ball in the basket from almost anywhere on the court, even impossibly far away. But as soon as a scrimmage started, I completely fell apart. If there was anyone else on the court, I couldn't concentrate. It didn't take the coach long to concede his dreams for me, and I never made it to a real season. Went back to individual sports, like swimming, where I excelled."

As I pulled the needle out of his skin I noticed his eyes were all crinkled up and there were tears forming at the corners. I worried that I had hurt him, but he started laughing uncontrollably.

"That is the funniest basketball story I have heard in a long time."

I smiled, pleased I was able to entertain him. I don't think I ever had a patient laughing while I was plunging a needle back and forth under their skin. I waited for the tech to stain the slides, and looked in the scope for a second time. Same thing.

I told him that we still had some material to process overnight, but so far the results were encouraging. His doctor may want to excise the lesion for a definitive diagnosis, but they could decide that together. I didn't have diagnostic material, but I wasn't seeing anything scary yet, either.

"Sometimes no news is good news. I hope that is the case for you."

He stepped out of the chair and I shook his hand.

"It was an honor to meet you sir. Good luck."


Gizabeth Shyder said...

Luer lock. That is the name of those syringes. I remembered on the treadmill this morning.

rlbates said...

You can come over and shot baskets with me in my back yard. Rusty only occasionally steals the ball.

Gizabeth Shyder said...

You and Rusty have to stay clear or I'll never make a basket:)

Sounds fun!